Writing with Scissors is the blog site of Howard Rodenberg, MD MPH, former Kansas State Health Director and columnist for the Journal of Emergency Medical Services (JEMS). He is a father, emergency physician, and slightly-past-fifty curmudgeon with great hair for his age. The "scissors" in question refer to those used by editors to weed out all things opinonated, controversial, or politically inappropriate...translated as "anything funny."

Monday, June 1, 2015

At the start of every
shift I go through my e-mails. I find it a nice way to ease into my workday,
and it's sort of fun to count the minutes you spend reading e-mails, multiply
it by the amount you're getting paid per minute (and make no mistake, every ER
doc knows what that number is), and realize you've just made money by clicking
on announcements of new hires you'll never encounter, seminars you'll never
attend, and the administrative glad-handing that passes for the aura of employee
relations.I could tell you that I'm
looking intently for updates on clinical
policies and care pathways that will lead to improved patient outcomes, or
opportunities to fulfillmy educational
needs, but the truth is I'm looking for Nastygrams.Those are the e-mails that start out with some
variation of "Remember that patient?" Any written communication that
starts this way is by definition bad.In
the ER world, good news is handed out in person, while bad news is always in
writing (to cover everyone involved except the proposed
offender).

(You can also use the “I
know how much I’m making per minute” theory when you’re doing personal tasks
like going to the bathroom.I like to think
about it when I’m fetching the patient some water or juice.It takes me two minutes to walk across the
ER, open the refrigerator, get the juice, fill a cup from the ice machine, find
a straw and a lid, and take it back to the patient, drag a tray over to the
bedside, open and pour…yep.Just bought
lunch.)

The Nastygrams come in
several varieties.The primary one is
the Patient Complaint.The patient disliked
something about what you did or didn’t do, and the Patient Advocate (now
there’s a neutral job title) and other Administrative Poobahs would like you to
review the chart before they confirm your anticipated guilt.If that sounds alarmist, it needs to be
understood that one of the current paradigms in health care is that the
customer (patient) is always right, no matter how that plays out against the
backdrop of clinical care.It’s all
about the satisfaction scores, about seeing the patient quickly, about making
sure they’re happy during their stay and leaving with a positive impression so
the patient, family, and friends will continue to seek care, and bring their
dollars, to this hospital.Which is all
well and good, and something to be pursued, until you recognize that a lot of
medicine doesn’t involve making people happy.It’s about doing the right thing and the right time within the limits of
your abilities and resources, and as often as not it means doing what might not
be considered optimal customer service.And if the scores come in low, no matter what the reason, it’s the
physician who’s on the hook because otherwise it’s a problem with the system,
and that might implicate the folks in suits.

Once you review the record,
the complaint is usually not a surprise; and if you've done your documentation
correctly (including direct quotes from the patient of phrases that rhyme with
"brother ducker," "whole mitt," and "brass mole"),
the Cubicle Dwellers have no choice but to reluctantly send a letter to the
patient apologizing for the hard feelings, but regretfully concluding the care
was appropriate. (The line, "It was documented that you acted like an orifice,
and our staff was exactly right to send you on your happy way," is apparently
not part of the template.)

(Speaking of which, my
colleagues and I recently got an e-mail from one of our Medical Directors
complimenting our group on the fact that there had been no patient complaints in
the prior two weeks.I sent back a note and explained that I was
on vacation.)

The “customer service”
mantra leads to a strange and costly practice of medicine, where tests are
ordered simply to be doing something or to meet patient expectations, drugs are dispensed to make patients
happy or simply because the doctor isn’t up for the fight (I think every ER doc
has experienced their own version of “Give’em What They Want Wednesday,”), and
the time needed to fully understand what’s going on with a patient, to set
realistic expectations for the ER visit, and to provide good explanations of
diagnoses or discharge instructions is truncated by the need to deal with those
complaining more loudly and threatening to leave.(I’ve never quite understood why, when
someone wants to leave the ER because they’re not being seen fast enough or
they don’t like the care they’ve received, we need to fall all over ourselves
to get them to stay.They are self-triaging
themselves back to the community despite our legally-obligated offer of care.Isn’t that what we want people to do…to take
control of their own health care?Yes,
unless their departure means less revenue.)

If clinical correlations
mean anything…as they rarely do in the world of customer service…there are
studies that suggest that more “satisfied” patients actually get worse health care
and experience worse outcomes.And what’s
more interesting is that those very things you can do to enhance customer satisfaction…like
taking more time with patients to provide teaching and explanations, making
sure family and friends are involved and informed, and going through discharge
instructions carefully and completely…work against the goal of enhanced patient
turnaround times. (More on that later.)

Which leads us to the
Nastygram by the Numbers.I truly do
think it's a welcome development that an increasing amount of medical care is
judged by objective criteria.For
example, if we know that patients should get certain medications after a heart
attack, and that old people should get influenza and pneumonia vaccines, it
makes sense to keep count of how many actually get the recommended care.These are objective, specific, and measurable
criteria proven to show a benefit to patient care.The problem is that many other criteria we're judged on,
especially in the ER, are totally abstract numerical goals without any clinical
basis or demonstrated outcomes.Many of
them are promulgated by what I think of as the "Center" industry,
which are those organizations set up to certify institutions as a Stroke Center, a Chest Pain Center, and others of that
ilk for a healthy fee.Which ultimately is not a clinical
designation, but a marketing one.(Ever
notice how no hospital markets itself as a "Methamphetamine
Center?"It's because the bean
counters don't want those folks...perhaps better termed as "non-revenue
clients"...darkening the door of their ER.Strokes and heart attacks mostly involve old people with Medicare, which
means payment. Meth intoxication?Not so
much.)

Despite the fact that
these criteria have no basis in reality, when one of them is not met the
Nastygram follows.For example, many
have heard of "clotbuster" treatment for strokes.The theory goes that if strokes are caused by
small blood clots that limit blood flow to the brain, these medications get
into the vessels and blast these clots away.The catch is that you have to give these medications under four hours or
so from the onset of the symptoms of stroke; beyond that time, the
risks of life-threatening bleeding from use of the drug outweigh any benefit
you might seeThe criteria is that once
the patient arrives in the ER, you have an hour from the moment the patient
walks through the door to give the medication.If it's given after that first hour, or there's no reason on the chart
why you didn't give the medication (not everyone qualifies and it's not universally
indicated), you "fall out" and your e-mail inbox fills.

Why one hour?Nobody knows.It's a totally abstract number.Nobody has ever been able to quantify how much brain tissue is lost
between 59 and 61 minutes.And while I
would surely agree that quicker treatment times are generally better, sometimes
you need to take the time to discuss with the patient and the family the risks
and benefits of treatment, and the speed of their decision process often does
not match yours. They may want to talk to additional family members, or you may
simply have problems finding anyone to talk to.Maybe you need some lab work to make sure the patient actually qualifies
for the drugs, or simply time to get the storystraight so you know what you're doing.And it's worth noting that in a recent study of Certified Stroke
Centers, the majority were unable to meet their own select criteria for
administration of the agent in less than an hour.Rather than citing unproven numbers with the force of law, wouldn't
it make more sense to track your own facility's times, come up with a goal, and
look for roadblocks in the process rather than to come down on individuals for
falling out on criteria that clinically means nothing and can't even be met by
the best of hospitals?

(And this is even without
addressing the very real clinical argument that the drugs may not be very
useful overall, and should not even be considered the standard of care.Once again the “Center’ industry…no doubt
supported by the pharmaceutical folks who make these drugs…has promulgated a
standard that may not even reflect the best practice in patient care.This is similar to what happened with the
standards for cardiac resuscitation over a decade ago, where a perfectly useful
and inexpensive drug called lidocaine used for irregular heartbeats was
magically replaced by a much more expensive and less useful agent called
amiodarone, and nobody could figure out if there was a connection between the
maker’s kind and generous support of the American Heart Association and its’
Clinical Investigators, and the change in standards.But I suppose this is all cyclical and really
nothing new.At one time I understand it
was popular to be a “Leech Center” as well.)

The most recent “quality
benchmark” has been proposed by the Department of Health and Human
Services.HHS has set a goal of getting
patients who will be discharged home in and out of the ER in a total time of
two hours.They’re even talking about it
being used as a reimbursement factor.Let’s
leave aside for the moment that this is a totally abstract number, and that
even the fastest doctor in our ER group did an experiment one month and
couldn’t get her patients out in less than 120 minutes no matter how hard she
worked.Given unlimited resources of staffing,
scores of empty patient rooms, and idle x-ray and laboratory machines just
begging for something to do, you could probably meet the goal.Nobody has that, and the two hour turnaround for
all discharged patients often becomes a totally unobtainable measure in any busy
ER that can’t be met without tricks of accounting (and there are ways to do
that, some legitimate, some not so much).

But the practical issues
beg the question of whether meeting this goal represents a measure of quality,
at least as defined in medicine.Fast
turnaround times are possible, as long as the patient has a straightforward
outpatient problem, sufficient ancillary resources are available to permit rapid
lab and x-ray evaluation, and the physicians and nurses are not otherwise
burdened with an excessive number of patients under care or even a single
critical patient which can take them ‘out of the system” for a prolonged period
of time.But that’s most often not the
case.As an emergency physician, the
nature of the work means I’m not fully dedicated to a single patient at a time,
and I can’t focus on moving that one patient through as quickly as I can.I’ve got up to ten or more patients to juggle
at a time, all with different issues, different levels of severity, and
different agendas and expectations that need to be resolved.Statistically speaking, the conflict is
really one of modeling ER flow.Throughput
goals are based on a linear model of patient arrival, departure, provider
workload, and client movement through the department.Patients being the subjective and unpredictable
creatures that they are, those with “boots on the ground” recognize that the ER
actually works on a non-linear model.Patient
show up when they choose or need to, have varied complaints, require different levels
of clinical and social interventions.Workload
for physicians and nurses follows a non-linear pathway as well.So turnaround times mean something, or nothing,
depending on who you ask; and as a result it’s hard to have a coherent dialogue
with between two mutually exclusive perspectives.And while shorter turnaround times no doubt
promote customer satisfaction, it’s an open question whether that is equivalent
to quality care, which brings us back to where we started.

Then there’s the Nursing
Complaint.As the power of Nursing Administration
(who represent the majority of "critical" employees) within the hospital
structure grows, the relative power of the physician ebbs.It's fine when the paternalistic (at best) or
authoritarian (at worst) physician-nurse relationships of the past become
collaborative in nature.But the
pendulum has swung so far that the
relationship is often adversarial, with the doctor considered guilty until
proven otherwise.Nurses are considered
rare prizes and hard to get, and hospitals commit to specific staffing ratios and
promotional schemes to keep and retain them; physicians are thought of as
interchangeable commodities, especially in this era when most ER docs work not
for themselves, but either as hospital employees or for an outside staffing
group whose bottom line is profit margin and keeping administration happy.So who becomes your more valuable asset when
conflict occurs?Especially in the ER,
where physicians provide no referrals to the hospital, do not expand the
financial footprint of the facility, and don't generate outside revenue for the
institution?

(I'll be the first to
admit I have little to no internal filter at work.But I always watch myself when I talk to
nurses, especially if I disagree with their assessment or they've made a
blatant error in care, because I know who's going to win that argument.It's not me.)

Don't misunderstand
me.It's not that doctors don't act like
jerks from time to time. They do, myself included, and some of us more often
than others.And we've all done things
in a moment of confusion of exhaustion that good nurses have caught and helped
us correct. When these behaviors become routine, we should probably get called
out on it, and in practice we do.But
since nurses are "owned" by administration in a way that doctors
aren't, they're routinely protected despite similar behaviors or a frank lack
of knowledge.

(Want to know something
else that really annoys me? Anonymous complaints.We're professionals.I'll sign my name to my concerns if you'll
sign yours as well.Otherwise, we both
lose the opportunity to confront each other in search of the truth, and to find
accommodation between our views.Or better
yet, just ask what I'm doing and why I’m doing it in real time.I really don't mind questions, and an ensuing
discussion if you've got a different point of view. But let's act like adults
here, okay?)

Finally, we come to the
Billing Questions, the subject of the most recent Nastygram to collect dust on
my electronic desk.It concerned a lab
test for hepatitis, and I was asked by the billing office why I ordered the test.The way the billing process works is that
anything ordered needs to link up to the discharge diagnosis according to
established criteria (the “criteria” industry is yet another moneymaker.)If the test does not relate in a
predetermined way to the discharge diagnosis, no payment for that test is forthcoming.

I went back to the chart
to find out what occurred.The patient
presented with a probable cellulitis, or skin infection.He had also come in with instructions from his
doctor to be tested for HIV, the virus that causes AIDS.He wanted this test done, and clinically when
I test for HIV I also test for hepatitis, which is also transmitted through
blood and body fluids (and which you are much more likely to contract from
exposure than HIV).They run together in
high-risk individuals, so it always made sense to me think that if you’re at
risk for one, you’re likely at risk for the other. And wouldn’t you like to
know in advance rather than be surprised one day when you wake up looking like
Chiquita Banana? Isn’t that good medical care?

But according to the
Billing Lords, with a diagnosis of cellulitis the test not indicted.So here’s the dilemma.We’re told that medicine is now all about
customer service, and I’m doing what both customers (the referring physician
and the patient) want done.I’m probably
helping to secure a referral base by honoring that doctor’s request, and
hopefully the patient will provide a glowing report back to him or her.But in the effort to enhance customer service
and provide quality care I've run up a charge that can’t be billed, and in
getting these extra tests I’ve probably increased my throughput times.I’m caught either way I turn.And none of these issues which come to haunt
me in the Nastygrams involve the actual provision of care for the patient’s skin
infection, which is to prescribe some antibiotics, advise the patient to
elevate and apply warm compresses to the leg, draw a marker line around the
area of redness to make sure it doesn’t get any worse, and wish the patient the
very best of the afternoon.

In reading back through
what I’ve written, I seem like nothing more than an angry old coot.There’s truth in that.I am highly frustrated with the current
practice of medicine for any number of reasons, but for the record I don’t
object to being judged in my work.I
simply want the standards to be fair and to mean something to clinical practice
and patient care, which should be my bottom line.And I want the playing field to be level, to
know that my word means something, and to know that the institution for whom I
work is actually on my side.I’ve been
in places where the hospital declared open war on physicians; fortunately,
that’s not the case where I practice now, and I hope the tide doesn’t turn
until I’m ready to hang it up for good.But
that spectre is always out there, and all it takes is one new administrator in
just the wrong place to tip the balance…as it inevitably will.

Thanks for reading.I’m sorry it’s taken so long today, but I’ve
been busy writing other paragraphs.I
really appreciate your patience and understanding.Please be sure to fill out your customer
satisfaction survey.Please make sure
you rate me as a “9” or “10,” because anything else is considered a
failure.If you like me, the name’s Dr.
Rodenberg.If you don’t, it’s Dr. Smith.Because we don’t have any of those here in
our ER.